FADavis Chapter 13: Nursing Care of Pts With Emergent Conditions and Disaster/Bioterrorism Response

What is the most important skill for a nurse to have when running triage?

To recognize an emergent condition and to prioritize life-saving care

Primary Survey

an initial assessment is conducted to identify the pts general status and recognize life-threatening conditions to determine priorities of care in critically ill or injured pts—use assessment tool AVPU, and then follow an organized approach like ABCs

A-Airway (ABCs)

• if pt is alert or responsive, have pt open their mouth to inspect the airway

• if pt is unable to open mouth, use jaw-thrust maneuver rather than chin-lift—don’t hyperextend, flex, or rotate neck until spinal injury ruled out

• checking for obstruction caused by tongue, loose or missing teeth, blood, emesis, edema, or foreign objects

• interventions to keep airway patent: object removal (if easy and possible), oropharyngeal suctioning, oropharyngeal or nasopharyngeal airway insertion, supraglottic airway insertion (laryngeal mask airway), retroglottic airway insertion (laryngeal tube airway), endotracheal intubation, cricothyroidotomy (needle or surgical) (done by specially trained EMT or HCP

B-Breathing (ABCs)

• pt then checked for spontaneous breathing and resp rate and depth, rise and fall of chest symmetry, use accessory muscles, and any open chest wounds.

• auscultate breath sounds bilaterally

• interventions for awake but spontaneous breathing: reposition, supplemental oxygen, or BiPAP

• interventions for absent resps or abnormal sounds: ventilation with mouth to mouth, bag valve, endotracheal intubation (preferred method)

C-Circulating (ABCs)

• a central pulse (carotid or femoral) is palpated for quality and rate. Check for warmth, color, and moisture

• external bleeding should be controlled by external pressure

• if extremity bleeding can’t be stopped with pressure, elevate and possibly apply tourniquet

• internal bleeding, shock, and burns can also compromise circulation without external blood loss

• Large IVs for fluid resuscitation (16-18g)

• Palpate pulse, check vitals—if no pulse, start CPR compressions

D-Disability/Central Nervous System (ABCs)

• brief neurologic assessment conducted using Glasgow

• best motor response+best verbal response+eye-opening=GCS score

E-Exposure (ABCs)

• complete visual assessment, remove clothing

• keep pt covered to reduce heat loss and prevent shivering

• look for injuries, uncontrolled bleeding, signs of illness, and medical alert jewelry

Secondary Survey

for victims of severe trauma; separates life-threatening from non-life-threatening

Components of Secondary Survey

• Head: inspect for lacerations, bleeding from orifices, check pupil size and response to light, are pupils equal in size?

• Chest: auscultate for breath sounds in all lung fields, inspect for lacerations, wounds, and foreign bodies

• Abdomen: auscultate for bowel sounds in all four quadrants, palpate for areas of tenderness and rigidity, inspect for lacerations, wounds, and foreign bodies, inspect for ecchymosis (bruising)

• Extremities: inspect for lacerations, wounds, and foreign bodies, insepct for injuries and deformities and note area of tenderness, palpate pulses, and evaluate temperature and capillary refill and compare the elft to the right extremities

Shock

a condition of progressively decreasing blood pressure , results in inadequate tissue perfusion. There are 4 types of shock.

1. hypovolemic shock—decrease in circulating blood volume

2. cardiogenic shock—results from cardiac failure

3. obstructive shock—caused by a blockage of blood flow in the cardiovascular circuit outside the heart

4. distributive shock—excessive dilation of the venules and arterioles

Anaphylactic Shock

• form of distributive shock; response to a severe allergic reaction that can progress to anaphylactic shock

• signs of severe anaphylaxis: respiratory distress with wheezing, stridor and cyanosis due to airway constriction and fluid, hypotension due to vasodilation, and decreased level of consciousness due to decreased oxygenation

• immediate tx of epinephrine, maybe added antihistamines, steroids, and oxygen

Why is it important to know the mechanism of injury for major trauma?

• Penetrating (open) may be caused by a sharp object (broken glass or a knife)

• Projectiles (closed) traveling at high speed (bullets, bomb fragments(

• Blunt Injuries (closed) skin surface intact (may extend beyond point of impact, ex. ribs crack and fragments cause inside laceration)

Surface Trauma

• closed and open wounds

• close: contusions and hematomas

• open: abrasion, puncture, laceration, avulsion, and amputations

Abrasion

a scraping away of the epidermal and dermal layers of the skin. Bleed very little but can be extremely painful because of inflamed nerve endings. dirt may be ground into it which increases the risk of infection

Puncture Wound

result from sharp, narrow objects such as knives, nails, or high-velocity bullets. They can often be deceptive in that the entrance hole can look normal, but there may be extensive damage to underlying organs. Bleed a bit less unless in chest or abdomen

Lacerations

Deep wound that form due to snagging or tearing skin tissue, irregular shape. Skin can be partially or fully torn away. Lots of bleeding especially if artery invovled.

Avulsion

edges cannot be approximated due to full-thickness skin loss—think lawn mower or chain saw accidents

Amputation

partial or complete severing of body part; in complete amputation, vessels spasm and then retract into tissue which makes bleeding more minimal than partial because lacerated arteries continue to bleed—bleeding must be controlled with pressure and elevation and tourniquet as last ditch effort—should be made of a wide material similar to a blood pressure cuff. Dressing is applied to the amputated extremity or stump. Stump is covered with sterile saline-moistened gauze followed by dry gauze and then held in place with elastic bandage for pressure. Try to keep amputated part for reattachment if possible

Tetanus

a disease caused by the bacillus “Clostridium tetani"—spores enter through open wound, spores produce toxins, toxins affect CNS by blocking inhibitor impulses causing muscles to contract and spasm—first sign is often lockjaw, later can be abdominal rigidity, difficulty swallowing and breathing, painful muscle stiffness, and seizures. Airway maintenance becomes a big consideration. Can be treated with human tetanus immune globulin IM, muscle spasm control, wound care, and tetanus toxoid booster. Should do Td as prescribed

Head Trauma

sharp blows to the head can cause shifting of intracranial contents—brain tissue contusion. Phase one: initial injury that is irreversible & intra-cerebral bleeding and edema from the initial injury—causes increased ICP

Early Signs adn Symptoms of Increased Intracranial Pressure

• headache

• nausea and vomiting

• amnesia

• changes in speech

• altered level of consciousness or drowsiness

Late Signs and Symptoms of Increased Intracranial Pressure

• dilated nonreactive pupils

• unresponsiveness

• abnormal posturing

• widening pulse pressure

• decreased pulse rate

• changes in respiratory pattern

Spinal Trauma

most often results from motor vehicle crashes, sports injuries, falls, and assaults. Cervical spine especially vulnerable to traumatic injury. All trauma pts should be treated as if they have sustained spinal trauma until proven otherwise. Moved only by healthcare workers. Stabilizing while moving is best with collar and backboard.

Chest Trauma

can damage heart and lungs and be life-threatening; may cause pericardial tamponade, hemothorax, tension pneumothorax, and flail chest; may also cause life-threatening injuries including pulmonary and myocardial contusion, aortic and tracheo-bronchial disruption, and diaphragmatic rupture; may also result in laceration of lung tissue—air or blood into intra-pleural space can collapse the lung (pneumothorax or hemothorax) resulting in inefficient ventilation

Flail Chest

condition of chest wall caused by two or more fractures on each affected rib, resulting in a segment of rib that is not attached on either end.

Cardiac Tamponade

when blood or fluid accumulates in the pericardial sac.

Abdominal Trauma

risky because of vital organs that are not protected by bones like chest are. Blunt force wound or penetrating wound to spleen and/or liver can result in hemorrhage because they are so blood rich which then can lead to hypovolemic shock. Trauma to urinary bladder may cause urine leaks into abdomen and blood at urinary meatus and perineum

Orthopedic Trauma

bone brakes and fractures can result in impaired circulation distal to the brake, if not realigned timely, necrosis can occur for both skin and bone tissue; pelvic fractures could cause problems for veins in hips and genitourinary system; thigh and femur breaks can result in massive blood loss; joint dislocations, similarly to breaks, can cause impaired circulation to dislocated limb and therefore necrosis of tissue.

Correlating Spinal Injury with Impairment of Motor Function

• S3 to S5 or above: pt unable to tighten anus

• L4 to L5 or above: pt unable to flex foot and extend toes

• L2 to L4 or above: pt unable to extend and flex legs

• C5 to C7 or above: pt unable to extend and flex arms

Burns

Burns impair skin function, causing fluid loss, infection, and temperature regulation issues. Serious complications and mortality risk increase with burn size and age (especially over 60). Immediate care involves the ABCDE survey, focusing on airway, breathing, circulation, and fluid resuscitation. Inhalation injuries are life-threatening, requiring monitoring and bronchoscopy. Fluid resuscitation is guided by burn size and patient weight, with IV fluids and opioids for pain. Burns are classified by depth, with treatments ranging from sterile saline and anti-infective cream for minor burns to specialized care for major ones.

Defining Characteristics for Hypothermia

• Below 95 degrees F (35 C)

  • alert but apathetic or irritable

  • vigorous shivering

  • skin cold to touch

  • lack of coordination

  • slurred speech

  • hypoglycemia from shivering

  • vitaI signs decrease

• Below 91.4 degrees F (33 C)

  • cardiac arrhythmias

  • cyanosis

• Below 89.6 degrees F (32 C)

  • shivering stops, muscles activity declines, then muscles rigid

  • lethargic, disoriented, hallucinating

  • dilated pupil

  • hypotension

• Below 82.4 degrees F (28 C)

  • hypoventilation (3 to 4 breaths per minute)

  • bradycardia, ventricular fibrillation possible

  • absent deep tendon reflexes

• Below 80.6 degrees F (27 C)

  • no vital signs detectable

  • fixed, dilated pupils

  • ventricular fibrillation to cardiac standstill

Frostbite and Frostnip

Frostnip is mild cold exposure causing pale, blanched skin without pain, easily warmed. Frostbite occurs when tissue freezes, often in extremities, causing hard, frozen, white or blue skin. Rewarming leads to red, hot skin. Severity depends on exposure duration, temperature, and wind. Treatment includes gentle handling, dry dressings, elevation, analgesics for pain, and medications to prevent clotting.

Hyperthermia

Hyperthermia occurs when the body’s heat regulation fails, leading to excessive heat buildup. It can result from heat generation, inability to dissipate heat, or environmental factors. Unlike fever, the thermal set point remains normal. At-risk groups include children, older adults, and those with heart disease. Antipyretics are ineffective and can worsen the condition.

Early Defining Characteristics for Environmental Hyperthermia

• core body temperature 100.4 degrees F to 102.2 degrees F (38C to 39C)

• diaphoresis

• cool, clammy skin

• alert, irritable, poor judgment

• dizzy, weak, headache

• vomiting, diarrhea

• pulse rate greater than 100

Late Defining Characteristics for Environmental Hyperthermia

• increasing body core temperature of 106 degrees F (41.1C) or higher

• inability to sweat

• hot, dry flushed skin

• altered mental status

• seizures or coma possible

• hypotension

Heat Cramps

the mildest form of heat illness. painful muscle spasms in legs or abdomen, happen after strenuous exercise—get adequate rest and fluid replacement, body adjusts the distribution of electrolytes and cramps will disappear

Heat Exhaustion

when so much water and electrolytes lost through sweating that hypovolemia occurs. a manifestation of the strain placed on the cardiovascular system as it tries to maintain normothermia. Body temp is normal or slightly elevated.

Heatstroke

altered mental status, inability to sweat. body temp rapidy rises to 106 and above, if not stopped, results in death. Late complications appear suddenly and include seizures, cerebral ischemia, acute kidney injury, late cardiac decompensation, and GI bleeding. Prognosis varies in length of time under heat stress and prior health

Inhaled Poisons

include carbon monoxide, chlorine, natural gas, pesticides, other gases. carbon monoxide causes profound hypoxia when combining with hemoglobin. chlorine inhalation can result in obstruction caused by pulmonary edema. pt removed from environment with poison, supplemental oxygen give as ordered

Injected Poisons

difficult to dilute or remove. usually result of OD. also can be from bites and stings of insects or animals. local swelling and tissue destruction at injection site. remove nearby jewelery which may impair circulation. cold pack applied to decrease pain and swelling. ID drug or toxin to manage

Insect Stings or Bites

cause anaphylaxis in small percentage of people. symptoms usually localized pain, swelling, heat and redness. tx is applying ice, elevating affected part. Cellulitis may become a complication

Snakebites

decrease circulation of venom, keep pt calm and immobilize affect body part until antivenin given, position below heart level. clean with soap and water. cover with loose clean dressing, don’t use tourniquet or ice

Near-Drowning

Near-drowning is survival after submersion in water. Drowning causes asphyxia; victims initially hold their breath, but reflexes lead to water aspiration and laryngospasm. Wet drowning allows fluid into the lungs, while dry drowning causes severe hypoxia. Risk factors include inability to swim, alcohol, exhaustion, and hypothermia. Outcomes depend on water temperature, submersion time, and the victim’s age. Symptoms of secondary near-drowning may appear up to 72 hours later, with potential respiratory failure, acidosis, and brain damage. Cold-water drowning may allow recovery if resuscitation is continued until the core temperature exceeds 90°F.

Psychiatric Emergencies

person no longer copes to maintain usual level of function. moods, thoughts, actions so disordered pt could harm self or others if not quickly controlled

Disaster Response

A disaster overwhelms existing resources and requires coordinated community and agency responses. Disasters can be internal (fires), external (floods), or created (accidents, terrorism). Emergency plans involve agencies like EMS, fire, and hospitals working together. Hospitals activate disaster plans for external and internal issues. Staff roles are outlined, and off-duty staff is called in. Casualties are triaged and treated based on severity and recovery potential.